Phacoemulsification of posterior polar cataracts.

Posterior polar cataracts present a unique challenge for the cataract surgeon. This review describes the steps a surgeon can take to overcome these challenges for the successful phacoemulsification of the posterior polar cataract. Proper preoperative examination and diagnostics will allow appropriate preoperative counseling and surgical planning to increase the likelihood of success. Specific techniques for each stage of the procedure are described, all with the aim of protecting the posterior capsule and preserving intraocular lens (IOL) fixation options. Posterior polar cataracts present dilemmas in preoperative evaluation, surgical management, and IOL fixation.

Phacoemulsification of the rock-hard dense nuclear cataract: Options and recommendations.

We describe the essential steps in the successful phacoemulsification of the rock-hard, dense cataract. Appropriate and directed preoperative history, physical examination, and diagnostics allow the surgeon to select the best incision, anesthesia, and intended surgical technique for a given dense nuclear challenge. Hard nucleus-specific approaches for hydrodissection, pupil management, and zonular protection then allow the surgeon to approach the rock-hard nucleus with maximum safety. Dense nuclear dismantling options are then discussed in detail along with fluidic and power modulation considerations. Various specific phacoemusification machine settings for rock-hard cataracts from the authors representing several different phaco systems are then presented. The combination of these steps and considerations allow a more successful dense cataract removal and potential restoration of vision for patients. This paper represents the collective experience and advice of the Challenging and Complex Cataract Surgery Subcommittee.

Vancomycin-Associated Hemorrhagic Occlusive Retinal Vasculitis: Clinical Characteristics of 36 Eyes.

PURPOSE: To expand understanding of presentation, diagnosis, and outcomes of hemorrhagic occlusive retinal vasculitis (HORV). DESIGN: Retrospective case series. PARTICIPANTS: Thirty-six eyes of 23 patients. METHODS: The American Society of Cataract and Refractive Surgery (ASCRS) and the American Society of Retina Specialists (ASRS) formed a joint task force to define clinical characteristics of HORV and to study its prevalence, cause, treatment, and outcomes. An online registry was established on both societies' web sites. Surveys were e-mailed to members of both societies soliciting cases of suspected HORV. A literature search was performed to uncover additional cases. MAIN OUTCOME MEASURES: Historical data including intraoperative characteristics, images, treatment regimens, and visual and anatomic outcomes. RESULTS: Characteristic findings of HORV included unremarkable postoperative day 1 undilated examination, delayed-onset painless vision loss, mild anterior chamber and vitreous inflammation, sectoral retinal hemorrhages in areas of ischemia, and predilection for venules and peripheral involvement. Based on predetermined diagnostic criteria, 36 eyes of 23 patients were diagnosed with HORV. All eyes received intraocular vancomycin via intracameral bolus (33/36), via intravitreal injection (1/36), or through the irrigation bottle (2/36). Patients sought treatment with HORV 1 to 21 days after surgery or intravitreal injection. Visual results usually were poor: 22 of 36 eyes (61%) had 20/200 or worse visual acuity and 8 of 36 eyes (22%) had no light perception (NLP). Neovascular glaucoma developed in 20 of 36 eyes (56%). Seven eyes received additional intravitreal vancomycin after surgery; 5 of these 7 eyes had NLP visual acuity at the most recent examination. Three eyes received intravitreal corticosteroids and had final visual acuities of 20/40, 20/70, and hand movements. CONCLUSIONS: Hemorrhagic occlusive retinal vasculitis is a rare, potentially devastating condition that can develop after cataract surgery or intraocular injection. All cases in this series were associated with intraocular vancomycin. Disease course and findings suggest that HORV is caused by a delayed hypersensitivity reaction to vancomycin. Early treatment with corticosteroids likely is beneficial. Subsequently, anti-vascular endothelial growth factor injections and panretinal photocoagulation are important to prevent neovascular glaucoma, a common complication. Avoidance of additional intravitreal vancomycin is recommended if HORV is suspected.

Cataract surgery and nonsteroidal antiinflammatory drugs.

Nonsteroidal antiinflammatory drugs (NSAIDs) have become an important adjunctive tool for surgeons performing routine and complicated cataract surgery. These medications have been found to reduce pain, prevent intraoperative miosis, modulate postoperative inflammation, and reduce the incidence of cystoid macular edema (CME). Whether used alone, synergistically with steroids, or for specific high-risk eyes prone to the development of CME, the effectiveness of these medications is compelling. This review describes the potential preoperative, intraoperative, and postoperative uses of NSAIDs, including the potency, indications and treatment paradigms and adverse effects and contraindications. A thorough understanding of these issues will help surgeons maximize the therapeutic benefits of these agents and improve surgical outcomes. FINANCIAL DISCLOSURE: Proprietary or commercial disclosures are listed after the references.

Targeted Next-Generation Sequencing Analysis of a Pendred Syndrome-Associated Thyroid Carcinoma.

Pendred syndrome is an autosomal recessive disorder characterized by hearing loss and goiter and is caused by bi-allelic mutations (homozygous or compound heterozygous) of the PDS (SLC26A4) gene. The incidence of Pendred syndrome is 7.5-10/100,000 in the general population, and it carries a 1 % risk of developing thyroid carcinoma. Herein, we report a case of a patient with Pendred syndrome who developed a follicular variant of papillary thyroid carcinoma (FVPTC)-that is approximately at an odd of 1/1,000,000. Targeted next-generation sequencing with ThyroSeq v2 was performed on the tumor, and only a TP53 mutation (TP53 p.R175H) was identified. The mutation was limited to the tumor nodule of FVPTC as shown by immunohistochemistry. This report represents the first extensive molecular study of a Pendred syndrome-associated thyroid carcinoma. The evidences support that thyroid carcinomas arising from dyshormonogenetic goiter require additional genetic alteration in addition to the purported thyroid-stimulating hormone (TSH) overstimulation. It is intrigue to note that the mutant p53 is involved in the development of a low-grade malignant thyroid tumor as FVPTC in this patient.

Cataract surgery in the small eye.

UNLABELLED: The surgical management of cataract in the small eye presents the ophthalmic surgeon with numerous challenges. An understanding of the anatomic classification in addition to a thorough preoperative assessment will help individualize each case and enable the surgeon to better prepare for the obstacles that might be encountered during surgery. Small eyes are especially challenging in terms of intraocular lens (IOL) calculations and possible current limitations of available IOL powers, which could necessitate alternative means of achieving emmetropia. Surgical strategies for minimizing complications and maximizing good outcomes can be developed from knowledge of the anatomic differences between various small-eye conditions and the pathologies that may be associated with each. A thorough understanding of the challenges inherent in these cases and the management of intraoperative and postoperative complications will ensure that surgeons approaching the correction of these eyes will achieve the best possible surgical results. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Minimally invasive external mini-glaucoma shunt implantation without conjunctival dissection.

The current method for implantation of the Ex-PRESS Glaucoma Filtration Device requires a conjunctival peritomy and shunt insertion under the guarded protection of a scleral flap. This technique requires suture closure of the flap and conjunctiva. A new minimally invasive technique for Ex-PRESS shunt implantation allows for insertion through a scleral tunnel originating from a grooved clear corneal incision. This new method avoids the need for conjunctival dissection and closure and offers the advantages of eliminating conjunctival wound leaks while maintaining the protection of a partial thickness scleral covering. This new technique may offer a faster safer means for shunt implantation with the potential for less conjunctival scarring.

Management of the subluxated crystalline lens.

The surgical management of ectopia lentis presents the ophthalmic surgeon with numerous challenges and options. From the clinical evaluation to the surgical approach, ectopia lentis patients require additional methodologies, techniques, and devices to ensure the best possible outcome. The continued refinement of surgical techniques and adjunctive prosthetic devices has led to incremental improvements in the ability to achieve successful in-the-bag placement and centration of intraocular lenses while reducing complications. A thorough understanding of the challenges inherent in ectopia lentis cases and the management of intraoperative complications will ensure that surgeons approaching the correction of these eyes will achieve the best possible surgical results.

Ocular zoonotic onchocerca infection in a resident of Oregon.

A long, slender filarial nematode was removed from the left anterior chamber of a resident of Oregon after several days of pain and blurred vision. The worm was identified as an Onchocerca, but it could not be further identified. This worm is the third zoonotic Onchocerca removed from the anterior chamber and the second case reported from the United States. Cases of zoonotic onchocerciasis continue to garner attention, and those cases affecting the eye are of particular interest.

Post-laser assisted in situ keratomileusis epithelial ingrowth and its relation to pretreatment refractive error.

PURPOSE: To assess the incidence of epithelial ingrowth after laser in situ keratomileusis and its correlation with myopic or hyperopic treatment. METHODS: This retrospective study analyzed 1000 consecutive LASIK procedures performed by 3 surgeons using identical surgical technique with a Hansatome microkeratome. Eyes that developed epithelial ingrowth were evaluated using the Machat grading system. Patients were subdivided into 2 groups (myopic or hyperopic) based on the preoperative refractive error. RESULTS: The total incidence of epithelial ingrowth was 4.7%. The incidence after primary treatment was 3.9%. The incidence after enhancement was 12.8%. The total incidence of epithelial ingrowth was 3% in the myopic group compared with 23% in the hyperopic group. After primary myopic treatment, there was a 3% incidence of epithelial ingrowth compared with 17% after primary hyperopic treatment. The incidence after enhancement was 7% in the myopic group and 43% in the hyperopic group. CONCLUSIONS: Patients undergoing hyperopic laser in situ keratomileusis have a greater incidence of epithelial ingrowth than those undergoing myopic treatment. In addition, enhancement procedures have a higher incidence than primary procedures.

Primary anterior chamber intraocular lens for the treatment of severe crystalline lens subluxation.

Subluxated cataractous and clear lenses are commonly treated by limbal or pars plana lensectomy followed by primary or secondary intraocular lens (IOL) implantation. Adjunctive capsular prosthetic devices have facilitated lens removal and IOL centration in these challenging cases but have also added complexity and potential complications to the procedure. Although crystalline lens extraction may be required to clear the visual axis in mild to moderate lens subluxations, we propose insertion of a primary anterior chamber IOL without lens extraction in severe subluxations when the eye is optically aphakic or can be made functionally aphakic following neodymium:YAG laser zonulysis. Two cases demonstrating this approach are presented.

Aspheric intraocular lens selection based on corneal wavefront.

PURPOSE: To determine the feasibility of selectively targeting zero total postoperative spherical aberration by selecting the best fit aspheric intraocular lens (IOL) based on preoperative topographically derived corneal spherical aberration. METHODS: Candidates for cataract surgery were offered selection of aspheric IOLs based on corneal spherical aberration. The target postoperative total wavefront spherical aberration Z4,0 was set at zero. Corneal topographic spherical aberration Z4,0 was measured at the 6-mm optical zone, and one of three aspheric IOLs was chosen so the arithmetic sum of the corneal spherical aberration and pseudophakic spherical aberration came closest to zero. Postoperatively, total ocular wavefront was measured and statistical analysis performed to ascertain the accuracy of customized aspheric IOL selection. RESULTS: Thirty eyes of 18 patients were available for analysis. The SofPort Advanced Optics (Bausch & Lomb) lens was implanted in 1 eye, the AcrySof IQ (Alcon Laboratories Inc) in 11 eyes, and the Tecnis Z9000 or Z9002 (Advanced Medical Optics [AMO]) in 18 eyes. Total postoperative ocular spherical aberration for the entire population measured -0.013+/-0.072 microm (SofPort: +0.025 microm; AcrySof IQ: +0.010+/-0.053 microm; and Tecnis: -0.015+/-0.052 microm [P=.22]). For the entire population, mean absolute predictive error measured 0.058+/-0.056 microm (SofPort: 0.040 microm; AcrySof IQ: 0.052+/-0.040 microm; and Tecnis: 0.063+/-0.066 microm [P=.631). CONCLUSIONS: Customized selection of aspheric IOLs based on corneal wavefront is feasible and produces favorable results compared with studies of unselected patient populations implanted with aspheric IOLs.

Persistent interface fluid syndrome.

We present an unusual case of persistent interface fluid that would not resolve despite normal intraocular pressure and corneal endothelial replacement with Descemet-stripping endothelial keratoplasty. Dissection, elevation, and repositioning of the laser in situ keratomileusis flap were required to resolve the interface fluid. Circumferential corneal graft-host margin scar formation acting as a mechanical strut may have been the cause of the intractable interface fluid.